Fax Severineb - MD Dental Services

DLP use only
Internal use only
Usage DLP
Usage interne
Name :
Reçu le :
DEP Chèq Poste TNT
N° Série
Plâtre
PE
GG
Mordu
FTP order # :
Date :
Order form for Narval CC™
ANGLETERRE
Patient information / Informations patient
Name______________________________________________________________________________________________________________ First Name
Nom
 This patient was fitted with Narval CC
________________________________________________________________________________
Prénom
TM
Ce patient a déjà été équipé d’une Narval CC
in the past
Age
TM
ID# ________________________________________________________________________
_________________________________
Age
Mandatory information to supply / Informations à fournir obligatoirement
OR
BITE REGISTRATION IN DESIRED PROTRUSION
 Bite registration in desired protrusion

Mordu en propulsion souhaitée
MEASUREMENTS IN MAX COMFORTABLE PROTRUSION
Distance from incisor 11 to 41 : _______________ mm
from end to end in max. comfortable protrusion
Distance entre les incisives maxillaires et mandibulaires

Please optimize the vertical
dimension (ResMed
recommended option)
OR

Veuillez optimiser la dimension
verticale
Please reproduce the vertical
dimension recorded by the
bite registration
Veuillez reproduire la dimension
verticale fournie par le mordu
Dental particularities to be taken into account


Teeth to protect : ____________________________
Dents à protéger


Midline deviation : _______________ mm
in max. comfortable protrusion
Déviation des milieux inter-incisifs


Right
patient
Left
patient
Gauche
Droite

Bite registration in centric occlusion in case of specific occlusion
Mordu en occlusion d’intercuspidie maximale en cas d’occlusion particulière
/ Particularités dentaires à nous signaler
Broken teeth :

_________________________________
Dents cassées
Complete lower overdenture
Prothèse totale inférieure sur implant
Other : _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Autre
Design preferences / Préférences de design
You can choose the design of the device for the upper and the lower splints. Please indicate your preferences below, otherwise
the default will be "VESTIBULAR BAND" or in the case of insufficient an "INCISOR FULL COVERAGE" will be created.
Vestibular band
 Upper / Haut
 Lower / Bas
Vestibular band with cap
 Upper / Haut
 Lower / Bas
 Please include all the molars
Je souhaite inclure toutes les molaires
Dentist Signature
Dentist Name :
Incisor full coverage
 Upper / Haut
 Lower / Bas
Palatal/Lingual band with
cap
 Upper / Haut
 Lower / Bas
 Please contact me if my preferences cannot be fulfilled
Palatal/Lingual band
 Upper / Haut
 Lower / Bas
 Please add slots for orthodontic bands
Je souhaite être contacté si mes préférences ne peuvent être respectées
Je souhaite des encoches pour élastiques
Delivery time: Please allow 3 calendar weeks from reception of your order by ResMed SAS
______________________________________________________________________________________________________________________________________________________________________________________
Date
_________
/_________ / _________
Signature
Nom du dentiste
Delivery address : ______________________________________________________________________________________________________________
Adresse de livraison
Stamp
__ _____________________________________________________________________________________________________________________________ ________________________________________________________________________________________________
Country :
_____________________________________________________________________________________________
Tel : __________________________________________________________
Pays
Email : __________________________________________________________________________________________________________________________________
To ensure your order is processed, please provide all information requested and follow the ordering instructions
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Ordering instructions for Narval CC™
1.
Please confirm that the patient is a good candidate for a mandibular repositioning device.
Before prescribing patients with Narval CCTM, you should look out for relevant issues in their medical history, such as respiratory disorders, asthma
and breathing problems, and refer them to the appropriate healthcare provider first.
The device is contraindicated for patients who:
- Have Central sleep apnea
- Severe respiratory disorder (other than OSA)
- Have loose teeth or advanced periodontal disease
- Are less than 18 years of age
- Have a completely edentulous arch
- Have a complete lower denture (not an overdenture)
- Have short teeth, insufficient undercuts to retain the device
- Don’t have at least 3 teeth (or implants/ permanent bridge) per
quadrant from the canine through last molar
2.
It is necessary to perform a dental, periodontal, prosthetic and TMJ
examination. The following dental issues must be treated by the
patient’s regular dentist before MRD treatment:
- Periodontal disease
- Cysts and mouth ulcers
- Teeth that need to be extracted
- Prosthodontics – such as crown or bridge
- Orthodontics
- Temporo-mandibular pain needs to be further assessed by
patient’s treating physician as well as any other TMJ disorder.
Provide the following information:
A - Bite Registration or measurements
BITE REGISTRATION:
- Provide a bite registration in desired protrusion using wax bite, or bite impression using George Gauge or a device of your choice. If you
use wax, please pay attention to the fact that wax can distort easily and requires to take extra precautions for transportation.
- You may ask ResMed to reproduce the vertical dimension recorded by your bite impression by ticking the box “Please reproduce the
vertical dimension”. In that case the bite registration should be at least 4mm thick. If a significant vertical dimension adjustment is
necessary (additional opening of 2°, which corresponds to approximately 3 mm), you will be contacted before production starts.
- ResMed’s clinical research suggests the vertical dimension to be minimised so as to ensure no posterior contact during advancement. If
you would like this option please tick “Please optimize vertical dimension”.
MEASUREMENTS:
- Please measure the distance between the upper incisor (N°11) and the lower incisor (N°41), from end to end, in mm and in maximum
comfortable protrusion.
- Where applicable, please provide direction and distance of midline deviation in maximum comfortable protrusion.
- Consider providing a bite in centric occlusion using material of your choice in case of special (prognathy, retrognathy) and/or unstable
occlusion.
- Initial mandibular protrusion will be set at approx. 60% of maximum comfortable protrusion.
- Vertical dimension will be minimised so as to ensure no posterior contact during advancement.
B - Impressions and/or plaster models
IMPRESSIONS:
- The impression material chosen should not be affected by transport (non-compressive silicon would be preferred for long distance
and/or weekend transportation and alginate should only be used for short distance transportation).
- We require a full impression of gingival sulcus and posterior molar area. Impressions must be taken with dentures in place (if any) and
must show the bottom of the sulcus in the full dental arch. PLEASE NOTE: these impressions will be discarded following the production
process.
MODELS:
- Please ONLY use a Type IV high strength material that can be scanned by CAD/CAM systems (matt and light colour preferred),
low expansion crown and bridge die stone that produces smooth, hard and accurate surfaces.
- Ensure bubbles are not present on the teeth surface or the gingival margin and that plaster models are less than 6 months.
3.
Send your order to your local ResMed approved dental laboratory. More info can be provided by your ResMed contact
Complete this order form and sent it out with :
Your ResMed approved dental lab address
Your ResMed contact


MD Dental Services (Laboratory) Ltd
Suite 102, 204 Baker Street,
London. EN1 3JY.
David Doey
020 82925181 / 07770847915
[email protected]
Disinfected bite registration and/or measurements
Disinfected impressions or models
Data Privacy: Personal data about the patient and the dentist is being processed for the purpose of the mandibular repositioning device production. The dentist is the data
controller and is responsible for compliance with applicable data protection law. ResMed has the role of a data processor and processes personal data on behalf of the
dentist. On request, the patient has the right to access, rectify and delete their personal data by contacting their health professional (dentist).
Manufactured & Distributed by: ResMed SAS Parc Technologique de Lyon, 292 allée Jacques Monod, 69791 Saint-Priest Cedex, France
Tel: +33 (0)4 26 100 200 · Fax: +33 (0)4 26 100 322· Email: [email protected]. LF-R2-18 ENG-ENG-RMD v4.0
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